PARADISE GARDENS

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility…This requirement was not met as evidenced by: Based on observations and interviews, the Licensee did not comply with section 87405(a) when the Administrator was unable to complete administrative duties due to performing caregiving duties… which is a potential health and safety risk to residents in care.

Official plan of correction

Administrator to provide a written statement that will detail the facilities plan that will ensure that section 87405(a) is met. Written statement to be provided to Licensing by 08/12/2025.

Deadline recorded: Aug 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.17(b)(1)(B)

Regulation authority

HSC

What the official deficiency says

(B) Any person, other than a client, residing in the facility. Residents of unlicensed independent senior housing facilities that are located in contiguous buildings on the same property as a residential care facility for the elderly shall be exempt from these requirements. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above in one out of two persons which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/07/2025 Plan of Correction Individual living in the house in the back of the faciltiy, should be cleared prior to living in the residence. Administrator was able to show DOJ clearance has now been received. Awaiting FBI letter.

Official classification

Type B

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in one out of one staff which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/07/2025 Plan of Correction Staff is cleared to work at alternate facility for same Licensee, but has not had prints transfered to this facility.

Official classification

Type B

Official code

1569.69(a)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed, the licensee did not comply with the section cited above in 6 out of 8 staff files which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/14/2025 Plan of Correction Administrator will update training logs and submit a plan for all staff to be trained.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 6 out of 6 resident files which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/14/2025 Plan of Correction Administrator to update resident files with current information, including updated medical assessments. Admission agreements should be completed and signed. Consent forms should be signed.

Official classification

Type B

Official code

87506(b)(10)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (10) Reports of the medical assessment specified in Section 87458 Medical Assessment, and of any special problems or precautions. This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed, the licensee did not comply with the section cited above in 4 out of 6 resident files which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/14/2025 Plan of Correction Residents do not have a current medical assessment. Arrangements should be made to either obtain the currect documentation or arrange for an assessment. Progress should be reported to LPA.

Official classification

Type B

Official code

87506(b)(13)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or the services he needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/14/2025 Plan of Correction Update of each residents status and condition, or illness. Update of ambulatory/ non-ambulatory, bedridden, etc.

Official classification

Type B

Official code

87463(b)

Regulation authority

CCR

What the official deficiency says

(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed, the licensee did not comply with the section cited above in no reappraisals have been completed which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/07/2025 Plan of Correction Status of new appraisals should be sent to CCL

Official classification

Type B

Official code

87463(e)

Regulation authority

CCR

What the official deficiency says

(e) The licensee shall immediately, or as soon as reasonably possible, bring any significant change in condition, as defined in Section 87101, Definitions, to the attention of the appropriate licensed medical professional and if applicable, other specialized care provider. Documentation of such communication shall be added to the resident's record and shall include: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in one out of 6 resident status changed and was not documented which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/07/2025 Plan of Correction Resident status on LIC602 said bedridden, but client status changed and is no longer bedridden. There is no documentation stating this change.

Official classification

Type B

Official code

87463(h)(1)

Regulation authority

CCR

What the official deficiency says

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 4 out of 6 resident files which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/07/2025 Plan of Correction Provide plan for all residents to recieve an updated medical assessment. If assessment has been completed, then proof of that visit to be obtained.

Official classification

Type B

Official code

87507(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/07/2025 Plan of Correction Resident files are not complete. Files should contain admission agreements or copies of originals.

Official classification

Type B

Official code

87633(b)

Regulation authority

CCR

What the official deficiency says

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above in one out of one residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/14/2025 Plan of Correction Hospice Plan should be updated regularly and should have an updated needs and assessment for residents.

Official classification

Type B

Official code

87633(h)

Regulation authority

CCR

What the official deficiency says

(h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident's record: This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above in one out of one which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/14/2025 Plan of Correction Hospice plan should be updated and needs and service plan should also be updated as per the hospice provider.

Official classification

Type B

Official code

87705(b)

Regulation authority

CCR

What the official deficiency says

(b) Licensees shall be responsible for the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in staff files reflecting training for dementia care which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/14/2025 Plan of Correction LPA did not observe dementia care training. All staff to have updated training by due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in the kitchen refrigerator, freezer, and the oven were either broken or completely inoperable which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/14/2025 Plan of Correction Facility should provide proof of service to repair or replace refrigerator and oven at the facility.

Official classification

Type A

Official code

1569.312(a)

Regulation authority

HSC

What the official deficiency says

§1569.312 Basic services requirements: Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement was not met as evidenced by: Based on interviews and record reviews, the licensee did not ensure all residents were provided care and supervision when R1 was able to exit the facility without staff knowledge, which posess an immediate health and safety risk to persons in care.

Official plan of correction

Licensee removed the pet door and installed a door sensor chime. POC cleared during inspection.

Deadline recorded: Jul 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above when a camera with audio was installed in bedroom 5, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/19/2024 Plan of Correction Camera has been removed. POC Cleared.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above when the following items were in need of repair: chair and ottoman in the living; exit door in the dining area, light bulb and faucet in the bathroom between bedroom 3 and 4, and the door track in bedroom 5. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/18/2024 Plan of Correction Licensee agrees to make the repairs by the POC due date. LPA will return at a later date to verify that repairs have been made.

Official classification

Type B

Official code

87468(c)(2)(A)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above when the facility did not have the correct size complaint poster and the poster was not placed in the entryway, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/18/2024 Plan of Correction Licensee agrees to obtain the correct PUB 475 poster and place the poster in the correct location by the POC due date. LPA will return at a later date to verify the correction has been made.

Official classification

Type B

Official code

1569.319(a)

Regulation authority

HSC

What the official deficiency says

(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use. This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews, the licensee did not comply with the section cited above when the facility did not have a device with internet access for residents in care, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/18/2024 Plan of Correction Licensee agrees to provide at least one internet access device to residents in care by the POC due date. LPA will return at a later date to verify if the correction has been made.

Official classification

Type B

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above when the facility did not have a supply of nonperishable foods for 7 days, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/18/2024 Plan of Correction Licensee agrees to obtain a 7 day supply of nonperishable foods by the POC due date. LPA will return at later date to verify if corrections have been made.

Official classification

Type B

Official code

87465(h)(1)(A)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (A) The preservation of medicines requires refrigeration, if the resident has no private refrigerator. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above when medications for R3 were not refrigerated which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/18/2024 Plan of Correction Licensee agrees to purchase a lock box to be used for medications that need to be refrigerated. LPA will return at a later date to verify if corrections were made.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above when 6 out of 6 residents did not have a complete record, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/18/2024 Plan of Correction Licensee agrees to update resident records to ensure each client has a complete record by the POC due date. LPA will return at a later date to verify if corrections were made.

Official classification

Type B

Official code

87464(f)(7)

Regulation authority

CCR

What the official deficiency says

Basic services shall at a minimum include: (7) A planned activities program which includes social and recreational activities appropriate to the interests and capabilities of the resident, as specified in Section 87219, Planned Activities. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above when the facility did not have a planned activity schedule in the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/18/2024 Plan of Correction Licensee agrees to develop a planned activities schedule based on resident likes and dislikes by the POC due date. LPA will return at a later date to verify if corrections were made.

Official classification

Type B

Official code

87507(a)(1)(A)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. (1) The text of the admission agreement, including any attachments and modifications, shall be: (A) Printed in black type of not less than 12-point type size, on plain white paper. The print shall appear on one side of the paper only. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above when 4 out of 6 residents have double-sided admission agreements, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/18/2024 Plan of Correction Licensee agrees to submit a written statement detialing how the facility will ensure the requirements for section 87101 are met. The plan should include a date when all admission agreements will be in compliance with Title 22 regulations. Licensee will submit the plan to the Fresno CCL office by the POC due date.

Official classification

Type B

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

(a)The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared, and served in a safe and healthful manner... this requirement was not met as evidenced by Based on observation and interviews, the facility did not comply with section 87555 when the facility accepted and used food donations that were past the best buy date, which is a potential health and safety risk to persons in care.

Official plan of correction

Administrator removed non-perishable foods from the pantry that were past the best buy date and removed discolored fruits and vegetables. Facility has begun shopping more frequently. POC CLEARED.

Deadline recorded: Feb 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.625(b)

Regulation authority

HSC

What the official deficiency says

(b) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 10 hours of training within the first four weeks of employment and four hours annually thereafter… This requirement was not met as evidenced by: Based on record review, the licensee did not ensure that all staff members received annual training. Record reviews revealed that 5 out of 9 staff did not have updated medication training which is a potential health and safety risk to persons in care.

Official plan of correction

Licensee agrees to write a statement detailing the steps the facility will take to ensure the requirements for section 1569.625 is met, to include the facility’s plan to have the 5 out of compliance staff complete the required medication training.

Deadline recorded: Feb 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465(h)The following requirements shall apply to medications which are centrally stored: (2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication... this requirement was not met as evidenced by: Based on observation, the facility did not comply with section 87465 when medication was found to be accessible to persons other than employees in the refrigerator in the garage, which is an potential health and safety risk to persons in care.

Official plan of correction

Administrator removed the medication from the garage and placed the medication in the medication cabinet preventing access to the medication to persons other than staff. POC Cleared.

Deadline recorded: Feb 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in out of 4 out of 6 persons who did not have appraisal of his/her individual service needs which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/12/2023 Plan of Correction Licensee agrees to update resident records to incldue an appraisal of his/her individual service needs by the POC due date. LPA will return at a later date to verify documents are in the facility file.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requrement was not met as evidenced by Licensee did not have cleaning supplies locked and were accessible to residents in care. Based on observation cleaning supplies were not locked and were accessible to residents in care on the garage floor which poses an immediate health and safety or personal rights risk to residents in care.

Deadline recorded: Jun 28, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in responsibilities when the need for such additional hours is substantiated by written documentation. This requirement was not met as evidenced by Based on interviews and records review the facility does not have a certified Administrator which poses a potential health safety and personal rights risk.

Deadline recorded: Jul 27, 2022. A deadline is not proof that correction was completed.